Provider Demographics
NPI:1255176749
Name:RICHARDSON, CORDERRIO JARROD
Entity type:Individual
Prefix:
First Name:CORDERRIO
Middle Name:JARROD
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 WELLER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-5064
Mailing Address - Country:US
Mailing Address - Phone:317-993-0139
Mailing Address - Fax:
Practice Address - Street 1:3311 WELLER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-5064
Practice Address - Country:US
Practice Address - Phone:317-993-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)